Efraim Jaul

Assessment and management of pressure ulcers in the elderly: current strategies.

Pressure ulcers (pressure sores) continue to be a common health problem, particularly among the physically limited or bedridden elderly. The problem exists within the entire health framework, including hospitals, clinics, long-term care facilities and private homes.For many elderly patients, pressure ulcers may become chronic for no apparent reason and remain so for prolonged periods, even for the remainder of the patient’s lifetime. A large number of grade 3 and 4 pressure ulcers become chronic wounds, and the afflicted patient may even die from an ulcer complication (sepsis or osteomyelitis).The presence of a pressure ulcer constitutes a geriatric syndrome consisting of multifactorial pathological conditions. The accumulated effects of impairment due to immobility, nutritional deficiency and chronic diseases involving multiple systems predispose the aging skin of the elderly person to increasing vulnerability.The assessment and management of a pressure ulcer requires a comprehensive and multidisciplinary approach in order to understand the patient with the ulcer. Factors to consider include the patient’s underlying pathologies (such as obstructive lung disease or peripheral vascular disease), severity of his or her primary illness (such as an infection or hip fracture), co-morbidities (such as dementia or diabetes mellitus), functional state (activities of daily living), nutritional status (swallowing difficulties), and degree of social and emotional support; focusing on just the wound itself is not enough. An understanding of the physiological and pathological processes of aging skin throws light on the aetiology and pathogenesis of the development of pressure ulcers in the elderly.Each health discipline (nursing staff, aides, physician, dietitian, occupational and physical therapists, and social worker) has its own role to play in the assessment and management of the patient with a pressure ulcer. The goals of treating a pressure ulcer include avoiding any preventable contributing circumstances, such as immobilization after a hip fracture or acute infection. Once a pressure ulcer has developed, however, the goal is to heal it by optimizing regional blood flow (by use of a stent or vascular bypass surgery), managing underlying illnesses (such as diabetes, hypothyroidism or congestive heart failure) and providing adequate caloric and protein intake (whether through use of dietary supplements by mouth or by use of tube feeding). If the ulcer has become chronic, the ultimate goal changes from healing the wound to controlling symptoms (such as foul odour, pain, discomfort and infection) and preventing complications, thereby contributing to the patient’s overall well-being; providing support for the patient’s family is also important. Recent advances in wound dressings allow for greater control of symptoms and prevention of complications, and have also enabled the affected patient to be integrated more readily into the family setting and in the community at large. Ethical and end-of-life issues must also be addressed soon after the wound has become chronic.This article discusses the pathogenesis of pressure ulcer development in the elderly in relation to concomitant diseases, risk factor assessment and the management of such ulcers.

Non-healing wounds: The geriatric approach

The most common types of non-healing wounds are four types: pressure ulcers, diabetic ulcers, ischemic ulcers and venous ulcers. Many of those wounds develop among the elderly, becoming non-healing to the extent that the patient may live with them all of his life, or even die because of them. Not enough attention is paid to the underlying contributing problems specific to the elderly patient. Those factors are physiologic (aging skin, immune state and atherosclerosis) and pathologic situation (diabetic disease, ischemia of leg). Therefore, the geriatric approach to a non-healing wound is comprehensive and multidisciplinary. Those including: patients co-morbidities, functional state as measured by the activities of daily living (ADL) scale, nutritional status, social support, ethical beliefs and quality of life and not only the wound itself. Each discipline (the nursing staff, physician, dietitian, occupational, physical therapists and social worker) has its own task in preventing and treating such wounds. The ultimate goal therefore has been altered from healing of the wounds to symptom control, prevention of complications and to contribute to the patients overall wellbeing. This review discusses all those items in a geriatric point of view, and how to deal with the non-healing wounds as a geriatric syndrome.

Systemic factors and mortality in elderly patients with pressure ulcers.

The aim of this article was to identify specific systemic factors associated with existence of pressure ulcers (PUs) and the effect on survival from the time of admission. Patients admitted to the Skilled Nursing Department of the Herzog Hospital, Jerusalem, between 1 July 2008 and 31 December 2011. Of the 174 admitted patients (mean age: 77·4 ± 13·2 years), 107 (61·5%) had pre‐existing PUs and 67 (38·5%) did not have PUs. Major systemic factors were assessed for each patient at the time of admission: sociodemographic characteristics, comorbidities, use of urinary catheter, tube feeding and tracheostomy; nutritional state; Global Deterioration Scale, Glasgow Coma Scale and Norton Scale. Complications such as the number of provided antibiotic courses, and length and outcomes of hospitalisation were identified at the end of the study. In the univariate analysis, patients in the PU group had significantly prevalent characteristics including advanced age, low cognitive and consciousness function, low Norton scale, Parkinsons disease and anaemia due to chronic diseases, low nutritional parameters and higher number of antibiotics provided. Conditions that were associated with PUs in multiple regression analyses included advanced dementia (OR = 3·0, 95% CI: 1·4–6·3; P = 0·002), urinary catheter usage (OR = 2·25, 95% CI: 1·06–4·7; P = 0·03), low body mass index, BMI (OR = 0·92, 95% CI: 0·86–0·99; P = 0·02) and anaemia level (OR = 0·7, 95% CI: 0·58–0·9; P = 0·004). The median survival time of patients with PUs was significantly lower than the non PUs group (94 versus 414 days, respectively) (P = 0·005, log rank test). Length of stay was also significantly lower in the PU group (166 versus 270 days, P = 0·02). The existence of PUs may indicate a final common pathway of various systemic factors (geriatric conditions, diseases and frailty dysfunction).

Osteoporosis in Tube‐Fed Bed‐Ridden Elderly Female Patients

To the Editor: In response to the letter from Dr. Lisi in this issue that expresses dismay at an editorial I wrote regarding an article by Gilstad and Finucane, opinion regarding how the system currently works, not advocacy for or against the publishing practices of the drug industry, accompanied my observations concerning rhetorics. I do not think it is ‘‘justified’’ for the pharmaceutical industry to inflate facts but do believe they are entitled to put forth their interpretations of data from studies or clinical trials, subject to limitation by peer review and journal editors. I agree with Dr. Lisi that pharmaceutical companies, like academic and all other authors, are accountable for what they write. I would again emphasize the importance of transparent declarations by authors regarding their roles in creating manuscripts, and their potential conflicts of interest, as well as independent editorials and letters to the editor, to give perspective to these communications. Finally, a major concern is that pharmaceutical companies publish or otherwise make available to the public data from all of their clinical trials with a given drug. Selective publication of positive trials may otherwise skew perspectives falsely inflating efficacy while minimizing adverse effects. The public should be able to see the ‘‘empty part of the glass as well as the full.’’ I also agree with Dr. Lisi that we can and should expect high standards in the medical publication process but believe that ‘‘buyer beware’’ will always remain an appropriate attitude when reading reports regarding benefits and limits of drug therapy. Martin R. Farlow, MD Department of Neurology School of Medicine Indiana University Indianapolis, IN

The Effect of Pressure Ulcers on the Survival in Patients With Advanced Dementia and Comorbidities

Background/Study Context: The mortality rates for many leading causes of death have declined over the past decade. Advanced dementia with comorbidities has steadily increased to become one of the leading causes of death in the elderly population. Therefore, this study examined the effect of pressure ulcers on the survival time of patients with advanced dementia and comorbidities. Methods: Data were reviewed from all the files of 147 patients hospitalized over a period of 3½ years. Ninety-nine tube-fed patients suffering from advanced dementia were assessed; 72 (66.5%) had pressure ulcers and 27 (33.5%) were without pressure ulcers at admission. Logistic regression analysis was used to estimate the odds ratio and 95% confidence intervals for pressure ulcers group versus non–pressure ulcers group. Unadjusted Cox model and Cox proportional hazards model were used to assess the hazard ratio for pressure ulcers and the association between pressure ulcers and survival time, respectively. Kaplan-Meier model was used to visually confirm the existence of proportional hazards of pressure ulcers on survival. Results: The median survival of advanced dementia patients with pressure ulcers was significantly shorter, compared with those without pressure ulcers (96 vs. 863 days). Significant lower hemoglobin and serum albumin levels were found in the patients with pressure ulcers. Conclusion: Advance dementia and pressure ulcers in the same patient results in earlier mortality. Advanced dementia patients with pressure ulcers had significantly lower survival expectancy in comparison with similar patients without pressure ulcers. Clinical and ethical implications are discussed.

Cohort study of atypical pressure ulcers development

Atypical pressure ulcers (APU) are distinguished from common pressure ulcers (PU) with both unusual location and different aetiology. The occurrence and attempts to characterise APU remain unrecognised. The purpose of this cohort study was to analyse the occurrence of atypical location and the circumstances of the causation, and draw attention to the prevention and treatment by a multidisciplinary team. The cohort study spanned three and a half years totalling 174 patients. The unit incorporates two weekly combined staff meetings. One concentrates on wound assessment with treatment decisions made by the physician and nurse, and the other, a multidisciplinary team reviewing all patients and coordinating treatment. The main finding of this study identified APU occurrence rate of 21% within acquired PU over a three and a half year period. Severe spasticity constituted the largest group in this study and the most difficult to cure wounds, located in medial aspects of knees, elbows and palms. Medical devices caused the second largest occurrence of atypical wounds, located in the nape of the neck, penis and nostrils. Bony deformities were the third recognisable atypical wound group located in shoulder blades and upper spine. These three categories are definable and time observable. APU are important to be recognisable, and can be healed as well as being prevented. The prominent role of the multidisciplinary team is primary in identification, prevention and treatment.

Systemic and Disease-Specific Risk Factors in Vascular Dementia: Diagnosis and Prevention

In order to prevent the onset of vascular dementia (VaD) in aging individuals, it is critical to detect clinically relevant vascular and systemic pathophysiological changes to signal the onset of its preceding prodromal stages. Identifying behavioral and neurobiological markers that are highly sensitive to VaD classification vs. other dementias is likely to assist in developing novel preventive treatment strategies that could delay the onset of disruptive psychomotor symptoms, decrease hospitalizations, and increase the quality of life in clinically-high-risk aging individuals. In light of empirical diagnostic and clinical findings associated with VaD pathophysiology, the current investigation will suggest a few clinically-validated biomarker measures of prodromal VaD cognitive impairments that are correlated with vascular symptomology, and VaD endophenotypes in non-demented aging people. In prodromal VaD individuals, distinguishing VaD from other dementias (e.g., Alzheimers disease) could facilitate specific early preventive interventions that significantly delay more severe cognitive deterioration or indirectly suppress the onset of dementia with vascular etiology. Importantly, the authors conclude that primary prevention strategies should examine aging individuals by employing comprehensive geriatric assessment approach, taking into account their medical history, and longitudinally noting their vascular, systemic, cognitive, behavioral, and clinical functional status. Secondary prevention strategies may include monitoring chronic medication as well as promoting programs that facilitate social interaction and every-day activities.

Age-Related Diseases and Clinical and Public Health Implications for the 85 Years Old and Over Population

By 2050, the American 85 years old and over population will triple. Clinicians and the public health community need to develop a culture of sensitivity to the needs of this population and its subgroups. Sensory changes, cognitive changes, and weakness may be subtle or may be severe in the heterogeneous population of people over age 85. Falls, cardiovascular disease, and difficulty with activities of daily living are common but not universal. This paper reviews relevant changes of normal aging, diseases, and syndromes common in people over age 85, cognitive and psychological changes, social and environmental changes, and then reviews common discussions which clinicians routinely have with these patients and their families. Some hearing and vision loss are a part of normal aging as is decline in immune function. Cardiovascular disease and osteoporosis and dementia are common chronic conditions at age 85. Osteoarthritis, diabetes, and related mobility disability will increase in prevalence as the population ages and becomes more overweight. These population changes have considerable public health importance. Caregiver support, services in the home, assistive technologies, and promotion of home exercise programs as well as consideration of transportation and housing policies are recommended. For clinicians, judicious prescribing and ordering of tests includes a consideration of life expectancy, lag time to benefit, and patient goals. Furthermore, healthy behaviors starting in early childhood can optimize quality of life among the oldest-old.

Paroxysmal theta power reactivity is related to survival in anoxic vegetative state patients

http://dx.doi.org/10.1016/j.clinph.2017.04.019 1388-2457/ 2017 International Federation of Clinical Neurophysiology. Disorders of consciousness (DOC) due to severe acute brain injuries (e.g., anoxic encephalopathy) are defined by loss of consciousness and absence of reactivity to external stimuli. DOC patients are often classified as being in a state of coma, a vegetative state (VS) or a minimally consciousness state (MCS) (Schorr et al., 2015). A shift in awareness from VS to MCS includes clinicallydefined behaviors such as visual fixation, directed reaction to stimuli, and congruent emotional responses. However, these cognitively mediated behaviors appear inconsistently, making it difficult to reliably identify them as non-reflexive behaviors (Fingelkurts et al., 2011). Hence, reliably predicting the clinical outcome and survival in DOC patients by employing behaviorally-based standard coma-recovery clinical-assessments is a major challenge in the clinical setting. These diagnostic tools (e.g., Coma-Recovery Scale-Revised, Lechinger et al., 2013) depend on observable responses, and are prone to result in a significant proportion of false negatives and misdiagnoses, which impair prognostic accuracy, and may lead to misinformed ethical considerations associated with important end-of-life treatment decisions (Fingelkurts et al., 2011). The current investigation aimed to examine whether certain neural electroencephalography (EEG) responses can surpass the standard clinical exams and resting EEG assessments in predicting survival in VS patients. EEG and diagnostic status were obtained from five anoxic vegetative state patients (925–3288 days from admission) at baseline (and from five healthy controls) followed by clinical outcome assessments at a post-10-months follow-up session. The VS group included five adult males, in a persistent vegetative state, ages 45–67 years. All VS patients suffered from severe brain damage following an acute anoxic brain event. Healthy controls (HC) included 5 males between 22 and 60 years, without psychiatric or neurological background. The study was conducted in accordance with the Helsinki declaration and approved by the institutional ethics committee. The JFK Coma Recovery Scale-Revised (CRS-R) and the Glasgow Coma Scale (GCS) were employed at baseline and at follow-up clinical outcome assessments (Morlet and Fischer, 2014). All VS patients had the same total CRS-R and GCS scores (CRS-R = 3, GCS = 7) at baseline EEG recordings. In the VS group, EEG was recorded at baseline followed by two follow-up clinical outcome assessments including survival outcome (survived or died 10 months after baseline EEG). The clinical assessments were conducted twice; once randomly over a period of less than 10 months after baseline EEG, and at 10 months following baseline EEG. EEG data were collected using a PC-based Neuroscan SCAN digital data system (ASA ANT, 32-channel system, Netherlands) at a sampling rate of 512 Hz with 0.16–256 Hz bandpass filter. Resting EEG and EEG oscillatory